BACKGROUND/RATIONALE:
According to the Institute of Medicine, up to 98,000 patients die and another 15 million are harmed in U.S. hospitals annually due to medical errors. Unwanted variation in communication during handoffs and transfers represent a vulnerable gap in care. For example, a Joint Commission Report issued in 2010 states, "Miscommunication between caregivers when responsibility for patients is transferred or handed-off plays a role in an estimated 80 percent of serious preventable adverse events."

Handoffs involve the transfer of rights, duties, and obligations from one person or team to another. In many high reliability industries such as aerospace, nuclear power, and recombinant DNA research, handoffs are critical and mistakes can be fatal. In these industries, handoff skills are formally taught and practiced repetitively, often using simulation and other educational techniques, to optimize precision and anticipate errors. In medicine, even though patient handoffs are critical to ensuring knowledge transfer, they are often unstructured and haphazard. As a result, the information transmitted to the on-duty provider during a handoff varies considerably. Similar observations have been made in handing off from inpatient to outpatient care.

OBJECTIVE(S):
In response to identified gaps in knowledge we designed a multi-method study of handoffs using direct observation, opportunistic interviews and shadowing to deepen our understanding of the social, linguistic and physical context in which handoffs are enacted. The project had two specific aims. The first aim was to identify barriers and facilitators to high reliability handoffs by directly observing physician/physician and nurse/nurse interactions in their naturally occurring contexts. The second aim was to determine how variations in physician/physician and nurse/nurse handoff processes impact subsequent care processes and outcomes.

METHODS:
This was a qualitative developmental study that focused on understanding the social, linguistic, and technological contexts in which nursing and medicine handoffs occurred at a single VA site, the Indianapolis VAMC. In the present study we audio and/or video recorded nursing and physician handoffs to understand variations in the stream and structure of verbal and non-verbal behavior that occur during these events. As compared with second order data sources such as interviews, direct observation of events allows researchers to describe the constitutive elements of an event, ceremony, or drama as it occurs in real time. We also used "opportunistic" interviews to try and understand what the experience of handing off or being handed off to was like for study participant. Our initial plan was to also shadow nurses and physicians after handoff had occurred but the logistics of shadowing become overwhelmingly complex and we were forced to abandon this component of the study.

FINDINGS/RESULTS:
In total, the study included 238 transfers of care on two medicine services and the surgery service. There were 31 nursing observations covering 137 patients and 21 resident transfers of care covering 101 patients.
Handoffs involve coordinated exchanges of information from one clinician to another using a variety of modalities including: 1) the use of formal and informal artifacts such as written sign-out sheets or "cheat sheets"; 2) information that is delivered verbally that includes paralinguistic features such as pitch, pace, intonation, and hesitations; and 3) non-verbal behavior which includes information that is delivered through gesture, posture, bodily orientation, facial expression, eye contact, and physical distance.
1. Use of artifacts- Outgoing nurses and residents used a variety of paper and electronic artifacts to conduct handoffs. Some used a printed handoff sheet that contained patient information, often augmented with additional notes on the printout or scraps of paper. CPRS was used as a memory aid in many of the nursing handoffs; fewer medical residents, and no surgical residents used the computer.
2. Verbal behavior- We noted several patterns of verbal behavior that characterized the observed handoffs. In general, nurses handed off by including a great deal of detailed information, both technical and psychosocial. Verbal transmission of information often included statements indicating ongoing relationships between nurses. Physicians, in general, handed of by exclusion, transmitting only pertinent positives in describing patients. Little psychosocial information was exchanged in these handoffs and there was little evidence of ongoing relationships between the physicians. We conclude that verbal information exchanged by nurses reflects their role of being at the bedside and actively engaging in carrying out orders and procedures. Physician handoffs, by contrast, were "managerial," and focused on a more global view of patients and problems to anticipate during an upcoming shift. In no cases, did nurses or physicians indicate whether they were handing patients off by acuity, room number, or randomly, a significant observations since experts in the field recommend handing off by acuity first.
3. Non-verbal behavior- We observed 4 recurring patterns of non-verbal behavior that were present in all settings. We have dubbed them: 1) joint focus of attention, in which both parties are focused visually and aurally on the same information; 2) "the poker hand;" in which one party transfers information by holding a paper artifact in such a way that the other cannot see what is written on it; 3) parallel play, in which each party is engaged in giving or receiving information without being able to see the other and, 4) curbside consultation in which one party stands during the handoff while the other is seated. Research in other high reliability industries, such as aviation, has demonstrated that joint focus of attention has the highest fidelity in terms of information transfer. In our study, joint focus of attention occurred infrequently while the "poker hand" and parallel play were far more frequent.

IMPACT:
Preliminary findings suggest that there is significant unwanted variability within and across professional roles, e.g., nurses and physicians, which relate to the use of artifacts, verbal, and non-verbal behavior. Future analyses are needed to better understand the potential impact of these variations on quality and reliability of care.